INSURANCE
Insurance Verification To determine if your insurance policy covers obesity (or "bariatric") surgery, refer to your insurance policy booklet or call your customer service agent. Typically, there are two sections that describe the extent and limits of coverage. The first is usually called "What Is Covered" or "Covered Expenses." These are the healthcare benefits for which the company will pay. Look for statements such as, "Surgery for the treatment of obesity is covered when deemed medically necessary," or "Surgery for the treatment of obesity is (specifically) excluded except when medically necessary." If this surgery is a covered benefit when medically necessary, then it should be covered when patients meet national guidelines for care for morbid obesity. See eligibility requirements below.
The other section is "What Is Not Covered" or "When the Plan Does Not Pay Benefits." In this section, look for any statement that the company excludes coverage for weight control, for the treatment of obesity, for the surgery for weight control, or for the complications of the surgery for weight control. Some policies will outright exclude bariatric surgeries. Others may have certain parameters around which bariatric procedures they cover and how much of the costs they cover.
THE INFORMATION BELOW IS A GENERAL GUIDE AND CAN NOT BE USED IN A DETERMINATION OF YOUR PERSONAL WEIGHT LOSS SURGERY BENEFITS. PLEASE REFER TO YOUR INDIVIDUAL POLICY FOR THE DETERMINATION OF YOUR ELIGIBILITY FOR COVERAGE.
Eligibility Requirements for Aetna
www.aetna.com
Documentation of morbid obesity that has persisted for over 5 years (formal documentation from a doctor’s visit);
BMI exceeding 40 OR BMI greater than of 35 with Co-Morbidities (Coronary Heart , Disease, Hypertension, Sleep Apnea, Diabetes); At least 18 years of age Has attempted weight loss in the past without successful long-term weight reduction AND Must meet either requirement; A. Has participated in a 6 month physician-supervised nutrition and exercise program within the last 2 years (physician’s summary letter of diet attempts is NOT sufficient documentation) Documentation in the medical record MUST include type of diet, exercise recommended or reason why you can’t exercise OR B. Multidisciplinary surgical preparatory diet of 3 months Dietician evaluation; Psychological evaluation addressing weight loss surgery.
Eligibility Requirements for Cigna
www.cigna.com
BMI of 40 for at least 12 months BMI of 35 for at least 12 months with at least 1 Co-Morbidity (Coronary Heart, Disease, Hypertension, Sleep Apnea, Diabetes); Has participated in a 6 month physician-supervised nutrition and exercise program within the last 2 years (physician’s summary letter of diet attempts is NOT sufficient documentation); Documentation MUST include type of diet, exercise recommended or reason why you can’t exercise; Documentation of morbid obesity that has persisted for over 5 years. (formal documentation from a doctor’s visit); Psychological evaluation addressing weight loss surgery; A recommendation letter from your primary care provider. At least 18 years of age; Dietician evaluation
Eligibility Requirements for Blue Cross Blue Shield
www.bcbs.com
BMI of at least 40 or BMI of at least 35 with Co-Morbidities (Coronary Heart Disease, Hypertension, Sleep Apnea, Diabetes); Documentation of morbid obesity that has persisted for over 5 years (formal documentation from a doctor’s visit); Psychological evaluation addressing weight loss surgery; A recommendation letter from your primary care provider. At least 18 years of age; Has participated in a 6 month physician-supervised nutrition and exercise program within the last 2 years (physician’s summary letter of diet attempts is NOT sufficient documentation); Documentation MUST include type of diet, exercise recommended or reason why you can’t exercise; Does not have a medically treatable case for the obesity.
Eligibility Requirements for Humana
www.humana.com
BMI of at least 40 with associated co-morbidity(Coronary Heart Disease, Hypertension, Sleep Apnea, Diabetes); Has participated in a 6 month physician-supervised nutrition and exercise program within the last 1 year (physician’s summary letter of diet attempts is NOT sufficient documentation); Documentation MUST include type of diet exercise recommended or reason why you can’t exercise; Psychological evaluation addressing weight loss surgery; A recommendation letter from you primary care provider; At least 18 years of age.
Eligibility Requirements for United Healthcare
www.unitedhealth.com
BMI of at least 40 or BMI of at least 35 with Co-Morbidities (Coronary Heart Disease, Hypertension, Sleep Apnea, Diabetes); Psychological evaluation addressing weight loss surgery; A recommendation letter from your primary care provider; At least 18 years of age; Has participated in a 6 month physician-supervised nutrition and exercise program within the last 2 years (physician’s summary letter of diet attempts is NOT sufficient documentation); Documentation MUST include type of diet; exercise recommended or reason why you can't exercise; Does not have a medically treatable case for the obesity.
Eligibility Requirements for Tricare/Champus
www.champus.com
BMI of 40 and has one of the following co-morbidities Diabetes, Hypertension, Gall bladder disease, Narcolepsy, Pickwickian Syndrome, Hypothalmic disorder, Severe Arthritis; BMI of 50 (an associated co-morbidity is not required)
Eligibility Requirements for Medicare
www.cms.com
BMI of at least 40 or BMI of at least 35 with Co-Morbidities (Coronary Heart Disease, Hypertension, Sleep Apnea, Diabetes); Under the age of 65 MUST UTILIZE A CENTER OF EXCELLENCE for Medicare reimbursement. If you have a secondary insurance with benefits, they WILL NOT pay if you choose not to follow the Medicare guidelines.
Appeals and Patient Financing
If coverage has been denied upon the initial prior authorization request, you can appeal by addressing the specific reasons why your request has been denied. You can also contact a lawyer with expertise to help you with the appeal. More information about legal help can be found at The Obesity Law and Advocacy Web site at www.obesitylaw.com